Multidisciplinary Consensus on the Management of Non-Invasive Respiratory Support in the COVID-19 Patient

Acute respiratory failure due to COVID-19 pneumonia often requires a comprehensive approach that includes non-pharmacological strategies such as non-invasive support (including positive pressure modes, high flow therapy or awake proning) in addition to oxygen therapy, with the primary goal of avoiding endotracheal intubation. Clinical issues such as determining the optimal time to initiate non-invasive support, choosing the most appropriate modality (based not only on the acute clinical picture but also on comorbidities), establishing criteria for recognition of treatment failure and strategies to follow in this setting (including palliative care), or implementing de-escalation procedures when improvement occurs are of paramount importance in the ongoing management of severe COVID-19 cases. Organizational issues, such as the most appropriate setting for management and monitoring of the severe COVID-19 patient or protective measures to prevent virus spread to healthcare workers in the presence of aerosol-generating procedures, should also be considered. While many early clinical guidelines during the pandemic were based on previous experience with acute respiratory distress syndrome, the landscape has evolved since then. Today, we have a wealth of high-quality studies that support evidence-based recommendations to address these complex issues. This document, the result of a collaborative effort between four leading scientific societies (SEDAR, SEMES, SEMICYUC, SEPAR), draws on the experience of 25 experts in the field to synthesize knowledge to address pertinent clinical questions and refine the approach to patient care in the face of the challenges posed by severe COVID-19 infection.

Real-world evidence of off-label use of commercially automated insulin delivery systems compared to multiple daily insulin injections in pregnancies complicated by type 1 diabetes

AIMS

To compare glycemic control and maternal-fetal outcomes of women with type 1 diabetes (T1D) using hybrid closed loop (HCL) vs. multiple daily insulin injections (MDI) plus continuous glucose monitoring (CGM).

METHODS

Multicenter prospective cohort study of pregnant women with T1D in Spain. We evaluated HbA1c and time spent within (TIR), below (TBR) and above (TAR) the pregnancy-specific glucose range 3.5-7.8 mmol/L. Adjusted models were performed for adverse pregnancy outcomes including baseline maternal characteristics and center.

RESULTS

112 women were included (HCL n=59). Women in the HCL group had a longer duration of diabetes and higher rates of prepregnancy care. There were no between-group differences in HbA1c in any trimester. However, in the second trimester, MDI users had a greater decrease in HbA1c (-6.12±9.06 vs. -2.16 ±7.42 mmol/mol, p=0.031). No differences in TIR (3.5-7.8 mmol/L) and TAR were observed between HCL and MDI users, but with a higher total insulin dose in the second trimester (+0.13 IU/Kg/d). HCL therapy was associated with increased maternal weight gain during pregnancy (βadjusted 3.20 kg, 95%CI 0.90-5.50). Regarding neonatal outcomes, newborns of HCL users were more likely to have higher birthweight (βadjusted 279.0 g, 95% CI 39.5-518.5) and macrosomia (ORadjusted 3.18, 95% CI 1.05-9.67) compared to MDI users. These associations disappeared when maternal weight gain or third trimester HbA1c were included in the models.

CONCLUSIONS

In a real-world setting, HCL users gained more weight during pregnancy and had larger newborns than MDI users, while achieving similar glycemic control in terms of HbA1c and TIR.

Universal radiation tolerant semiconductor

Radiation tolerance is determined as the ability of crystalline materials to withstand the accumulation of the radiation induced disorder. Nevertheless, for sufficiently high fluences, in all by far known semiconductors it ends up with either very high disorder levels or amorphization. Here we show that gamma/beta (γ/β) double polymorph Ga2O3 structures exhibit remarkably high radiation tolerance. Specifically, for room temperature experiments, they tolerate a disorder equivalent to hundreds of displacements per atom, without severe degradations of crystallinity; in comparison with, e.g., Si amorphizable already with the lattice atoms displaced just once. We explain this behavior by an interesting combination of the Ga- and O- sublattice properties in γ-Ga2O3. In particular, O-sublattice exhibits a strong recrystallization trend to recover the face-centered-cubic stacking despite the stronger displacement of O atoms compared to Ga during the active periods of cascades. Notably, we also explained the origin of the β-to-γ Ga2O3 transformation, as a function of the increased disorder in β-Ga2O3 and studied the phenomena as a function of the chemical nature of the implanted atoms. As a result, we conclude that γ/β double polymorph Ga2O3 structures, in terms of their radiation tolerance properties, benchmark a class of universal radiation tolerant semiconductors.

Safety and efficacy evaluation of the automatic stepwise recruitment maneuver in the neonatal population: An in vivo interventional study. Can anesthesiologists safely perform automatic lung recruitment maneuvers in neonates?

BACKGROUND

A new software has recently been incorporated in almost all new anesthesia machines to enable automatic lung recruitment maneuvers. To date, no studies have assessed the safety and efficacy of these automatic software programs in the neonatal population.

AIMS

We aimed to evaluate the safety and efficacy of the lung recruitment maneuver performed using the automatic stepwise recruitment maneuver software of the FLOW-i 4.3 Anesthesia System^® in a healthy and live neonatal model.

METHODS

Eight male newborn piglets were included in the study. The lung recruitment maneuver was performed in pressure-controlled ventilation with a constant driving pressure (15 cmH₂ O) in a stepwise increasing positive end-expiratory pressure (PEEP) model. The target peak inspiratory pressure (PIP) was 30 cmH₂ O and PEEP was 15 cmH₂ O. The maneuver lasted for 39 seconds. The hemodynamic variables were monitored using the PICCO^® system. The following respiratory parameters were monitored: oxygen saturation, fraction of inspired oxygen, partial pressure of oxygen and carbon dioxide in the arterial blood, end-tidal carbon dioxide pressure, PIP, plateau pressure, PEEP, static compliance (C_stat ), and dynamic compliance (C_dyn ). Safety was evaluated by assessing the accuracy of the software, need for not interrupting the maneuver, hemodynamic stability, and absence of adverse respiratory events with the lung recruitment maneuver. Efficacy was evaluated by improvement in C_stat and C_dyn after performing the lung recruitment maneuver.

RESULTS

All lung recruitment maneuvers were safely performed as scheduled without any interruptions. No pneumothorax or other side effects were observed. Hemodynamic stability was maintained during the lung recruitment maneuver. We observed an improvement of 33% in C_dyn and 24% in C_stat after the maneuver.

CONCLUSIONS

The automatic stepwise recruitment maneuver software of the FLOW-i 4.3 Anesthesia System^® is safe and efficacious in a healthy neonatal model. We did not observe any adverse respiratory or hemodynamic events during the implementation of the lung recruitment maneuver in the pressure-controlled ventilation mode using a stepwise increasing PEEP (30/15 cmH₂ O) approach.

Summary of Recommendations and Key Points of the Consensus of Spanish Scientific Societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the Use of Non-Invasive Ventilation and High-Flow Oxygen Therapy with Nasal Cannulas in Adult, Pediatric, and Neonatal Patients With Severe Acute Respiratory Failure

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analog classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

Hypertrophic cardiomyopathy surgery: Perioperative anesthetic management with two different and combined techniques

Hypertrophic cardiomyopathy (HOCM) is the most common genetic heart disorder and the most common cause of sudden cardiac death among young population and a major cause of disability for patients of any age. An extended transaortic septal myectomy is the definitive treatment. It is very important to have a good knowledge of the characteristic pathophysiology of the disease in order to optimize intraoperative treatment of these patients. We present a case of a 68-year old woman who underwent hypertrophic elective cardiomyopathy surgery. Anesthetic management is crucial to guarantee maximum safety, since HOCM has the capacity to produce hemodynamic events of such severity that put patient's life at risk. The use and combination of intraoperative transesophageal echocardiography (TEE) and direct measurement of the left ventricular outflow tract gradient provides vital information to ensure successful surgical outcome in patients with HOCM.

Summary of Recommendations and Key Points of the Consensus of Spanish Scientific Societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the Use of Non-Invasive Ventilation and High-Flow Oxygen Therapy with Nasal Cannulas in Adult, Pediatric, and Neonatal Patients with Severe Acute Respiratory Failure

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

Clinical consensus recommendations regarding non-invasive respiratory support in the adult patient with acute respiratory failure secondary to SARS-CoV-2 infection

Coronavirus disease 2019 (COVID-19) is a respiratory tract infection caused by a newly emergent coronavirus, that was first recognized in Wuhan, China, in December 2019. Currently, the World Health Organization (WHO) has defined the infection as a global pandemic and there is a health and social emergency for the management of this new infection. While most people with COVID-19 develop only mild or uncomplicated illness, approximately 14% develop severe disease that requires hospitalization and oxygen support, and 5% require admission to an intensive care unit. In severe cases, COVID-19 can be complicated by the acute respiratory distress syndrome (ARDS), sepsis and septic shock, and multiorgan failure. This consensus document has been prepared on evidence-informed guidelines developed by a multidisciplinary panel of health care providers from four Spanish scientific societies (Spanish Society of Intensive Care Medicine [SEMICYUC], Spanish Society of Pulmonologists [SEPAR], Spanish Society of Emergency [SEMES], Spanish Society of Anesthesiology, Reanimation, and Pain [SEDAR]) with experience in the clinical management of patients with COVID-19 and other viral infections, including SARS, as well as sepsis and ARDS. The document provides clinical recommendations for the noninvasive respiratory support (noninvasive ventilation, high flow oxygen therapy with nasal cannula) in any patient with suspected or confirmed presentation of COVID-19 with acute respiratory failure.

This consensus guidance should serve as a foundation for optimized supportive care to ensure the best possible chance for survival and to allow for reliable comparison of investigational therapeutic interventions as part of randomized controlled trials.

[Clinical consensus recommendations regarding non-invasive respiratory support in the adult patient with acute respiratory failure secondary to SARS-CoV-2 infection]

La enfermedad por coronavirus 2019 (COVID-19) es una infección del tracto respiratorio causada por un nuevo coronavirus emergente que se reconoció por primera vez en Wuhan, China, en diciembre de 2019. Actualmente la Organización Mundial de la Salud (OMS) ha definido la infección como pandemia y existe una situación de emergencia sanitaria y social para el manejo de esta nueva infección. Mientras que la mayoría de las personas con COVID-19 desarrollan solo una enfermedad leve o no complicada, aproximadamente el 14% desarrollan una enfermedad grave que requiere hospitalización y oxígeno, y el 5% pueden requerir ingreso en una unidad de cuidados intensivos. En casos severos, COVID-19 puede complicarse por el síndrome de dificultad respiratoria aguda (SDRA), sepsis y shock séptico y fracaso multiorgánico. Este documento de consenso se ha preparado sobre directrices basadas en evidencia desarrolladas por un panel multidisciplinario de profesionales médicos de cuatro sociedades científicas españolas (Sociedad Española de Medicina Intensiva y Unidades Coronarias [SEMICYUC], Sociedad Española de Neumología y Cirugía Torácica [SEPAR], Sociedad Española de Urgencias y Emergencias [SEMES], Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor [SEDAR]) con experiencia en el manejo clínico de pacientes con COVID-19 y otras infecciones virales, incluido el SARS, así como en sepsis y SDRA. El documento proporciona recomendaciones clínicas para el soporte respiratorio no invasivo (ventilación no invasiva, oxigenoterapia de alto flujo con cánula nasal) en cualquier paciente con presentación sospechada o confirmada de COVID-19 con insuficiencia respiratoria aguda.

Esta guía de consenso debe servir como base para una atención optimizada y garantizar la mejor posibilidad de supervivencia, así como permitir una comparación fiable de las futuras intervenciones terapéuticas de investigación que formen parte de futuros estudios observacionales o de ensayos clínicos.

Clinical Consensus Recommendations Regarding Non-Invasive Respiratory Support in the Adult Patient with Acute Respiratory Failure Secondary to SARS-CoV-2 infection

La enfermedad por coronavirus 2019 (COVID-19) es una infección del tracto respiratorio causada por un nuevo coronavirus emergente que se reconoció por primera vez en Wuhan, China, en diciembre de 2019. Actualmente la Organización Mundial de la Salud (OMS) ha definido la infección como pandemia y existe una situación de emergencia sanitaria y social para el manejo de esta nueva infección. Mientras que la mayoría de las personas con COVID-19 desarrollan solo una enfermedad leve o no complicada, aproximadamente el 14% desarrollan una enfermedad grave que requiere hospitalización y oxígeno, y el 5% pueden requerir ingreso en una Unidad de Cuidados Intensivos. En casos severos, COVID-19 puede complicarse por el síndrome de dificultad respiratoria aguda (SDRA), sepsis y shock séptico y fracaso multiorgánico. Este documento de consenso se ha preparado sobre directrices basadas en evidencia desarrolladas por un panel multidisciplinario de profesionales médicos de cuatro sociedades científicas españolas (Sociedad Española de Medicina Intensiva y Unidades Coronarias [SEMICYUC], Sociedad Española de Neumología y Cirugía Torácica [SEPAR], Sociedad Española de Urgencias y Emergencias [SEMES], Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor [SEDAR]) con experiencia en el manejo clínico de pacientes con COVID-19 y otras infecciones virales, incluido el SARS, así como en sepsis y SDRA. El documento proporciona recomendaciones clínicas para el soporte respiratorio no invasivo (ventilación no invasiva, oxigenoterapia de alto flujo con cánula nasal) en cualquier paciente con presentación sospechada o confirmada de COVID-19 con insuficiencia respiratoria aguda.

Esta guía de consenso debe servir como base para una atención optimizada y garantizar la mejor posibilidad de supervivencia, así como permitir una comparación fiable de las futuras intervenciones terapéuticas de investigación que formen parte de futuros estudios observacionales o de ensayos clínicos.

A new successful therapy for fetal chylothorax by intrapleural injection of maternal blood

We present two cases of fetal chylothorax and hydrops diagnosed at 20 weeks' gestation, both of which underwent successful intrauterine treatment. In Case 1, a transient, near total resolution began 2 weeks after an iatrogenic hemothorax following a second thoracocentesis performed at 24 + 6 weeks. Because of pleural fluid reaccumulation, a Cesarean section was performed at 36 weeks. The 3805-g female neonate was admitted to neonatal intensive care but was discharged 50 days later in a healthy condition. In Case 2, resolution occurred after a third thoracocentesis and a second pleural injection of maternal blood, performed at 26 weeks. A 2660-g female neonate was delivered vaginally at 38 weeks. The infant remained asymptomatic and was discharged aged 4 days. Our experience suggests a possible useful role of intrapleural blood injection for the treatment of fetal chylothorax.

Scanning electron microscopy of the wild boar and pig lingual papillae

Lingual papillae of wild boar and pig were studied by means of scanning electron microscopy (SEM). Vallate papillae appear with the typical circumvallate morphology. Their papillary bodies show conical or fungiform-like and spicule-like pseudopapillae in both animals. Taste pores were seen in the papillary grooves. Microplicae or pits are visible at high magnification. In pig and wild boar similar foliate papillae were observed. Pig has less but wider leaves than wild boar. Taste pores on papillary walls were viewed. At high magnification microplicae were seen. Morphologically, fungiform papillae correspond with their denomination. Taste pores open onto the upper surface and they are easily identifiable by SEM. The rostral and lateral regions contain the major number of fungiform papillae. The lateral papillae of wild boar and pig show a high number of pores per papilla. These regions must be considered important in taste sensitivity. Lateral papillae in both animals could provide a source of taste buds for study. In both animals the fungiform papillary epithelium showed a pitted appearance as a consequence of keratinization by food environmental stress. The filiform papillae can be both simple and compound (with body and hairs). Large conical papillae are located caudally and curved in the same direction. Filiform and conical papillae have a function in food mastication, handling and deglutition.

Fungiform papillae of the pig and the wild boar analyzed by scanning electron microscopy

Fungiform papillae of wild boar and pig were studied by scanning electron microscopy (SEM). Four regions were defined on the tongue: rostral, medial and caudal thirds and lateral sides. Morphologically the fungiform papillae correspond with their denomination. Rostral and lateral tongue regions presented the largest average number of fungiform papillae. Taste pores opened onto the upper surface of the papillae and were easily identifiable by SEM. The total number of fungiform taste pores from both animals was the highest reported in the literature. The lateral papillae of wild boar and pig contained the largest average number of pores per papilla. This region must be important in taste sensitivity. Lateral and rostral papillae from both animals can provide a source of taste buds for study since each fungiform papilla presents numerous taste buds and these papillae are very abundant.

A study of the chick thymus microenvironment during development: analysis by monoclonal antibodies against thymic epithelium

The process of T-lymphocyte differentiation within the thymus involves a series of molecular interactions. In this work we have carried out an analysis of the chick thymus microenvironment in order to evaluate its heterogeneity during development. We have produced 11 monoclonal antibodies whose staining patterns detected by the immunoperoxidase technique allowed us to divide them into five groups. A first group (E19-E2, P0-E5, and P15-T1) binds to thymic medullary stroma showing a reticular pattern on medullary epithelial cells and whose significance would be related to thymic stromal secretion. The second group of monoclonal antibodies (P15-T3) stains thymic corpuscles of 10- and 15-day chicks. The third group of antibodies includes P0-E1, P0-E3, P5-A6, and P15-T2 whose staining pattern is both medullary and cortical. The fourth group (P10-HB1 and P10-HB2) binds to thymic stromal and cortical thymocytes, and the fifth group (P5-A1) is characterized by the staining of medullary vessels of 5-day chicks. These five groups of monoclonal antibodies corroborate the existence of an antigenic diversity of the chick thymus microenvironment. Their possible relationships with T-cell differentiation and stromal-thymocyte interactions are discussed.

Simultaneous determination of toluene and xylene metabolites in urine by gas chromatography

A gas chromatographic method for simultaneous determination of hippuric and o-, m-, and p-methylhippuric acids (metabolites of toluene and xylene) in urine is described. The analytical procedure is based on the extraction of the aromatic metabolites with ethyl acetate containing the internal standard and on a methylation with 3-methyl-1-p-tolyltriazene. With this method, which does not require much time and handling, the different acids can be satisfactorily determined with high sensitivity and specificity. A statistical study shows a good reproducibility for the determination of hippuric and o-, m-, and p-methylhippuric acids. The coefficient of variation for 10 determinations in all cases was less than 5%.

Direct evidence of luteal insufficiency in women with habitual abortion

Plasma levels of progesterone were measured during the luteal phase in 10 of 15 women with clinical histories of at least three spontaneous abortions in the last three gestations, and in 15 healthy nonpregnant women during the same phase of the ovarian cycle. Progesterone values found in the women with habitual abortion were lower (P less than 0.05-0.005) than in the nonpregnant group almost throughout the period of observation. The habitually aborting women who became pregnant again aborted between the seventh and 12th weeks. Their progesterone concentrations were less than 6 ng/ml, 48-72 hours before vaginal bleeding or abortion. These values were compared with those found during the first 12 weeks in normal pregnancy (P less than 0.001). The results suggest a useful method of evaluating the treatment of habitual abortion.

Trichloroethylene exposure. Simulation of uptake, excretion, and metabolism using a mathematical model

The absorption, distribution, and excretion of trichloroethylene, as well as the kinetics of formation and elimination of trichloroethanol (TCE) and trichloroacetic acid (TCA) were simulated by a mathematical model. The results of this model have been satisfactorily compared with those obtained experimentally from pulmonary elimination of the solvent and from urinary excretion of the metabolites. The model permitted a study of the distribution of the solvent in the different tissues of the organism as well as an evaluation of the body burden of TCE and TCA. The influence of the duration and repetition of the exposure on the urinary eliminations of TCE and TCA was studied, and showed that the excretion of the first metabolite represents the most recent exposure while that of the second is related to the average exposure of the preceding days. The study of the pulmonary elimination of trichloroethylene during single or repeated exposures showed a linear relationship between the alveolar concentration of the solvent approximately 15 hours after the end of the exposure and the quantity of trichloroethylene accumulated in the fatty tissues.